IDSA News - March 2009
Vol. 19 No. 3
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New Influenza Guidelines Released

A new IDSA guideline for seasonal influenza in adults and children provides evidence-based recommendations for diagnosis, treatment, chemoprophylaxis, and institutional outbreak management.

A new IDSA guideline for seasonal influenza in adults and children provides evidence-based recommendations for diagnosis, treatment, chemoprophylaxis, and institutional outbreak management.                                                                   

The guideline addresses diagnostic issues, such as who should be tested, which tests should be used, and interpretation of results.  Recommendations for determining which specimens should be collected for influenza tests, and when they should be collected, are also provided.  For instance, obtaining respiratory tract specimens at the onset of illness should be done within five days of diagnosis.  The guideline cautions that in order to properly perform and analyze influenza tests, clinicians should understand the limitations of the tests and the rate of influenza activity among the population being tested.  

Several recommendations are outlined regarding who should be considered for antivirals, both for treatment and for chemoprophylaxis.  Although influenza vaccination is the primary tool to prevent influenza, antiviral chemoprophylaxis can be considered for high-risk individuals who are in jeopardy of developing complications from influenza (e.g., persons who are immunocompromised) and who cannot receive vaccine.  The guideline states that clinicians should be aware of local patterns of influenza throughout their communities when determining who should receive antiviral drugs and which antivirals should be administered. 

The guideline also discusses the occurrence of outbreaks in institutional settings, which can occur even when there is only one reported case of influenza.  In such cases, the recommendation is that all residents and institutional employees should be tested for influenza when symptomatic, and all residents should receive chemoprophylaxis whether or not they have previously been vaccinated.  Individuals receiving antiviral chemoprophylaxis in an institutional outbreak should remain on medication for at least 14 days.    

The guideline’s performance measures emphasize that all persons with acute febrile respiratory symptoms should be tested for influenza, and health care institutions should offer influenza vaccine to all employees.  Additional performance measures are outlined in the guideline to help health care practitioners measure the effectiveness of the guideline recommendations. 

The guideline is available online. Other IDSA guidelines also are available on the Standards, Practice Guidelines, and Statements page of our website.

CDC Calls for Stepped-up Efforts against Carbapenem-resistant Bugs

The Centers for Disease Control and Prevention (CDC) is advising acute care facilities to take steps to control the spread of carbapenem-resistant Enterobacteriaceae (CRE) now, before these deadly and hard-to-treat pathogens become widespread.

The Centers for Disease Control and Prevention (CDC) is advising acute care facilities to take steps to control the spread of carbapenem-resistant Enterobacteriaceae (CRE) now, before these deadly and hard-to-treat pathogens become widespread.

CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) issued new guidance on controlling these infections in the March 20 Morbidity and Mortality Weekly Report. In a March 17 conference call, CDC officials said they were highlighting the issue because CRE is a growing threat but one that can be contained with aggressive infection control measures.

“The time to act to control CRE is now,” said Arjun Srinivasan, MD, medical director of the Get Smart for Healthcare program at CDC’s Division of Healthcare Quality Promotion.

According to CDC, 8 percent of healthcare-acquired Klebsiella isolates reported to the National Healthcare Safety Network were carbapenem resistant in 2007, compared with less than 1 percent in 2000. Treatment options are limited for these extremely bad bugs, which are associated with higher mortality, longer hospital stays, and increased costs. The infections have been identified in 24 states and are regularly found in certain hospitals in New York and New Jersey.

The good news, Dr. Srinivasan said, is that they have not yet taken hold nationwide, and basic infection control procedures have successfully controlled the spread of CRE in recent outbreaks in Puerto Rico, Illiniois, and Israel.

The new guidance builds on HICPAC’s 2006 guidelines for managing multidrug-resistant organisms. It recommends that all acute care facilities implement contact precautions for patients with CRE, including isolation, glove and gown use, and hand hygiene. Clinical microbiology laboratories should put in place protocols recommended by the Clinical and Laboratory Standards Institute (CLSI) to detect resistant strains—including the use of a modified Hodge test for strains that have elevated, but still susceptible, minimal inhibitory concentrations (MICs) for carbapenems—and alert infection control staff if they are found.

CDC and HICPAC recommend that acute care facilities go back through their clinical culture data for the past six to 12 months to check for previously overlooked CRE. If positive cultures are identified, facilities should conduct active surveillance of high-risk units such as intensive care units and other wards with high antibiotic use. If any hospital-onset cases or colonized patients are found, contact precautions should be implemented, patients with epidemiologic links to the cases should be screened for CRE colonization, and periodic active surveillance should continue until no new isolates are found.

 “The history of the spread of antimicrobial resistance has taught us that without a vigorous multi-pronged approach these strains become widespread and take over from the more susceptible organisms,” said Edward Septimus, MD, FIDSA, a member of IDSA’s Board of Directors and Antibiotic Resistance Work Group. “We have already observed this with methicillin-resistant Staphylococcus aureus. The steps CDC is recommending will help us get out in front of CRE.”

Slides from the March 17 conference call, which include pictures of the modified Hodge test, are available online.

Long-awaited FDA Guidance on CAP Drugs Released

A major barrier to new antibiotic development has come down: The Food and Drug Administration (FDA) has released long-awaited guidance for companies developing drugs for the therapy of community-acquired pneumonia (CAP).

A major barrier to new antibiotic development has come down: The Food and Drug Administration (FDA) has released long-awaited guidance for companies developing drugs for the therapy of community-acquired pneumonia (CAP).

“It’s a home run,” said David Gilbert, MD, FIDSA, a member of IDSA’s Antimicrobial Availability Task Force (AATF), who has spearheaded the Society’s efforts with FDA on pneumonia drugs. He said the lack of clear guidance from FDA on how the agency would evaluate clinical trials for CAP drugs has kept many companies on the sidelines.

IDSA has been calling on FDA to release this guidance since the beginning of the decade. The issue came to a head in the summer of 2007, when FDA indicated that its previous guidance was no longer valid but did not offer an updated version. This left companies with no roadmap for how to conduct trials for these badly needed drugs.

“We know that companies have drug candidates out there that they have been holding back, saying we don’t want to go through $500 million [doing a clinical trial] without knowing the rules of the game,” Dr. Gilbert said.

Following FDA’s 2007 announcement, IDSA offered to co-sponsor a workshop to get together regulators, industry representatives, and other interested parties to hash out the issues. Dr. Gilbert credits Office of Antimicrobial Products Director Edward Cox, MD, MPH, for agreeing to the workshop and enthusiastically supporting the idea and then providing much-needed funding. The workshop was held in January 2008, and the proceedings were published in a Clinical Infectious Diseases supplement.

The guidance appears to take on board much of the advice that came out of that workshop. AATF member Brad Spellberg, MD, FIDSA, said the parameters laid out in the guidance are reasonable—but just having guidance is a huge step forward by itself. “Does that mean the [drug development] floodgates are going to open? Not necessarily. But one of the barriers has been knocked down.”

One potential sticking point for drug developers: The new guidance requires that in order for a patient to be enrolled in a trial, the pathogen must be identified—a notoriously tricky task in community-acquired pneumonia. Some in industry feel this will mean enrolling prohibitively large and expensive trials. However, Dr. Gilbert sees the requirement as a plus because it will stimulate development of better diagnostic tools to identify the pathogens that cause CAP. “Finally, we’re going to apply the tools of molecular diagnostics to clinical trials of community-acquired pneumonia,” he said. In the future, he sees diagnostics manufacturers pairing up with drug manufacturers, similar to the pairing of HIV tropism assays and maraviroc.

With FDA coming through with CAP guidance, IDSA is optimistic about the prospects for similarly long-awaited guidance on health care-associated and ventilator-associated pneumonia. IDSA and FDA are co-sponsoring a HAP/VAP workshop at the end of March.

IDSA Journal Club

March 2009

This month: nephrotoxicity of adjunctive gentamicin; fluoroquinolone-resistant meningitis; declining MRSA CLABSIs; inactivated flu vaccine outperforms live-attenuated vaccine in healthy adults; multidrug-resistant gram-negatives on the rise; and possible new drugs for XDR TB.

In this feature, a panel of IDSA members identifies and critiques important new infectious diseases studies in the current literature that have a significant impact on the practice of infectious diseases medicine.

Nephrotoxicity of Adjunctive Gentamicin for Staph Bacteremia and Endocarditis
Reviewed by Christopher Graber, MD

Initial, short-course, low-dose gentamicin as adjunctive treatment of S. aureus bacteremia and endocarditis was associated with a high rate of nephrotoxicity in an analysis published in the March 15 issue of Clinical Infectious Diseases

The study was a safety data analysis of the randomized trial comparing daptomycin to standard therapy (an antistaphylococcal penicillin or vancomycin combined with initial low-dose gentamicin, typically for four to five days), originally published in the New England Journal of Medicine in 2006.  Overall, 27 of 122 (22 percent) patients receiving initial low-dose gentamicin experienced clinically significant nephrotoxicity, including 15 of 34 patients (44 percent) with a baseline creatinine clearance of 50-80 mL/min.  The rate at which patients developed clinically significant nephrotoxicity was similar when low-dose gentamicin was given with antistaphylococcal penicillins or vancomycin.  Increase in serum creatinine peaked at day 7 in patients receiving antistaphylococcal penicillins, while serum creatinine increased over the 28-day study course in patients receiving vancomycin.

The findings call into question current American Heart Association guidelines that suggest the “optional” addition of initial low-dose gentamicin to antistaphylococcal penicillins for the treatment of native valve MSSA endocarditis. 

The study was limited by the fact that the randomized trial was not specifically designed to assess the effect of initial low-dose gentamicin on renal function, and only seven patients received standard therapy without initial low-dose gentamicin, thus preventing any analysis of its efficacy. 

This study follows another recent report in Clinical Infectious Diseases that estimated a 0.5 percent decrease in endogenous creatinine clearance per day of gentamicin adjunctive therapy used in the treatment of 373 patients with infective endocarditis caused by a variety of organisms (18 percent were S. aureus), a change that was not associated with post-discharge mortality. 

(Cosgrove et al, Clin Infect Dis 2009;48:713-21)

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Fluoroquinolone Resistance Seen in Meningitis Cases

Reviewed by Edward Dominguez, MD, FIDSA

Add another organism to the growing list of emerging fluoroquinolone-resistant pathogens in North America.

This brief report in the New England Journal of Medicine describes a cluster of three cases of meningitis caused by ciprofloxacin-resistant serogroup B Neisseria meningitidis in North Dakota and Minnesota. This particular isolate appears to have occurred via horizontal gene transfer of a DNA gyrase mutation (T91I) from a nasopharyngeal commensal, Neisseria lactamica. The cluster isolates had 99.9 percent similarity with N. lactamica in the 1,265 nucleotides surrounding the T91I mutation. Although the isolate of N. lactamica itself did not possess the mutation, the authors suggest that the probability of a point mutation was high given the use of ciprofloxacin in decolonizing contacts of an earlier case of meningococcal meningitis in the community.

Such resistance has been described in several other countries spanning several continents. However, no imported cases have yet been described. Although the T91I mutation is present in N. gonorrhea species, DNA sequence homology with N. lactamica implicated the commensal as the likely source of the resistant mutation.

Ciprofloxacin chemoprophylaxis for meningococcus is attractive in adults because it is a single dose with minimal side effects. However, regional health authorities recommended the alternatives of ceftriaxone or rifampin once ciprofloxacin resistance is identified.

Additionally, the authors describe a carriage survey in which three of the 40 (8 percent) meningococcal isolates identified had an MIC to azithromycin of 2.0 micrograms per milliliter, the limit of susceptibility. As azithromycin is another alternative for chemoprophylaxis, resistance to it may be just around the corner.

(Wu et al., N Engl J Med. 2009;360:886-892)

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MRSA Central Line-associated Bloodstream Infections Declining; Reasons Not Clear
Reviewed by Nina Kim, MD

The incidence of methicillin-resistant Staphylococcus aureus (MRSA) central line-associated bloodstream infections (CLABSIs) decreased from 2001 to 2007, according to a study by the Centers for Diseases Control and Prevention (CDC) and published in the February 18 Journal of American Medical Association.

This report originates from data collected by CDC’s National Nosocomial Infections Surveillance (NNIS), a voluntary hospital-based reporting network that evolved into the National Healthcare Safety Network (NSHN). A total of 33,587 CLABSIs were reported from 1,684 intensive care units and more than 16 million patient-days, of which 7.4 percent were MRSA and 4.7 percent methicillin-sensitive Staphylococcus aureus (MSSA). Aggregated percent MRSA (of all S. aureus CLABSIs) increased from 48 percent in 1997 to 65 percent in 2007. However, although the incidence of MRSA CLABSIs increased from 1997 to 2001, it later declined by almost 50 percent through 2007. The incidence of MSSA CLABSIs declined steadily from 1997 to 2007 by 60-78 percent. In addition, declines in the incidence of total (non-pathogen-specific) CLABSIs of 38-54 percent were observed across ICUs from 1997 to 2007. The authors emphasize the importance of examining the incidence of MRSA infections over percent MRSA as a more accurate metric of disease burden.

While the decline in MRSA CLABSIs is encouraging, it is worth noting that these bloodstream infections represent only a subset of all invasive nosocomial MRSA infections including other MRSA bacteremias. The study reviewed an impressive number of patient-years but reflects the voluntary self-report of only a fraction of hospital ICUs across the country. Many of these hospitals did not report continuously to the NNIS/NSHN database during the study years.

These results raise but do not answer the pressing question: What prevention and control measures contributed to this decline? In a time of increased public scrutiny and debate over the best way to control invasive MRSA infections in health care settings, this study underscores the importance of outcomes research in this area.

(Burton et al., JAMA 2009; 301:727-736)

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Trivalent Inactivated Flu Vaccine Better than Live-attenuated Flu Vaccine in Healthy Adults?
Reviewed by Nina Kim, MD

Trivalent inactivated influenza vaccine (TIV) was associated with fewer medical encounters related to pneumonia or influenza than live attenuated influenza vaccine (LAIV) in healthy military personnel who received annual immunization, according to a study from the March 4 issue of the Journal of American Medical Association.

The study was based on longitudinal data collected as part of routine surveillance of military health care and included more than 1 million active-duty service members aged 17-49 who were stationed in the United States during the 2004-5, 2005-6, and 2006-7 influenza seasons and able to receive either TIV or LAIV. The primary outcome measure was incidence of medical encounters for pneumonia or influenza by ICD-9-CM visit codes. The highest incidence occurred in unimmunized persons: 19.4, 10.9, and 11.7 events per 1000 person-years for the three consecutive seasons. The next highest incidence occurred in LAIV-immunized persons: 18.3, 10.6, and 11.1 per 1000 person-years. The lowest incidence was found in TIV-immunized persons with 8.6, 7.8, and 8.0 person-years respectively. Compared to the unimmunized group, the effect of vaccination with TIV was greater (28-55 percent) compared with LAIV (11-21 percent). Interestingly, LAIV appeared to perform better in vaccine-naïve cohorts and the difference between LAIV and TIV was not significant in this group for the 2005-6 and 2006-7 seasons.

This report stands in contrast to some observational data that suggest LAIV may be slightly more effective than TIV in children and highlights the importance of studying the effects of influenza immunization in different adult populations. A major limitation of this study, as with any observational study, is possible selection bias. The authors attempted to mitigate this by propensity-based matching but could not account for some key confounders such as smoking. Misclassification might also have been introduced with the use of diagnosis codes instead of lab confirmation.

Despite these limitations, this large study involved a closed population of healthy adults and provides reasonable estimates of incidence. Future studies should examine the relative efficacy of LAIV compared with TIV in other immunized groups such as health care workers.

(Wang et al., JAMA 2009; 301:945-953)

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Startling Rise of Multidrug-Resistant Gram Negatives
Reviewed by Paul Pottinger, MD

This paper serves as a sobering reminder of the importance of multidrug-resistant (MDR) gram-negative rods (GNR) in particular among elderly patients admitted to the hospital.

In this retrospective case-control study, the authors report the antimicrobial susceptibility patterns and clinical characteristics associated with gram-negative bacteremia diagnosed at admission among 724 patients aged 65 and older who were admitted to Beth-Israel Deaconess Medical Center from 1999-2007.  

Findings were striking: During the study period, the incidence of MDR increased from 1 percent of all gram negative bloodstream isolates to 16 percent.  Fifty-eight percent of patients were presumed to have a urinary source because the same organism grew in both urine and blood cultures.  Statistically significant risk factors for MDR GNR bacteremia included admission from a long term care facility [OR 4.9], presence of an indwelling device [OR 6.0], exposure to a week or more of antibiotics within the previous 90 days [OR 5.5], severe sepsis [OR 7.9], and delayed effective therapy [OR 12.8].  Indeed, the most significant finding of this paper is arguably the fact that 63% of case patients were started on empiric antimicrobial therapy that was ultimately found to be ineffective.  This is one possible explanation for the fact that patients with MDR GNR bacteremia had a higher incidence of mortality (18 percent) than their non-MDR controls (5 percent).  

At a glance, these findings may tempt us to prescribe broad-spectrum antibiotics routinely for elderly patients being admitted to the hospital.  Of course, this would be a recipe for accelerating the emergence of drug resistance.  The true strength of this study is its description of specific risk factors that should prompt careful consideration of early empiric broad-spectrum antibiotics—combined with early de-escalation of coverage once susceptibility data are available.  Put another way, carbapenems are may be good for what ails your patient, but their judicious use remains crucial for delaying or preventing the emergence of resistance.  In fact, the CDC has just updated its guidelines for controlling infections caused by carbapenemase-producing Enterobacteriaceae. (Also described in this issue of IDSA News.)

(Pop-Vicas et al.  Infect Control Hosp Epidemiol 2009;30:325–331)

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Meropenem-Clavulanate for the Treatment of XDR M. tuberculosis
Reviewed by Shireesha Dhanireddy, MD

Meropenem plus clavulanate is potentially effective against extensively-drug resistant (XDR) Mycobacterium tuberculosis, according to a study in the February 27 issue of Science.

Worldwide mortality remains high from M. tuberculosis. The increasing prevalence of multi-drug resistant (MDR) and XDR M. tuberculosis has led to limited treatment options and increased mortality.

Beta-lactam antibiotics have not been effective against M. tuberculosis due to the presence of a highly active, chromosomally encoded beta-lactamase. Recent genetic knockout studies demonstrated that M. tuberculosis strains lacking blaC-encoded beta-lactamase were more sensitive to beta-lactam antibiotics.

Clavulanic acid, a beta-lactamase inhibitor, irreversibly inhibits BlaC. Moreover, meropenem has the ability to inhibit BlaC as well as being a poor substrate for BlaC (leading to less inactivation of the drug).

In vitro studies using the combination of meropenem and clavulanate against M. tuberculosis found a low minimum inhibitory concentration and resulted in a rapid reduction in colony-forming units and complete sterilization by 9-12 days. The effect of this combination of antibiotics was also studied against “persistent” or viable non-replicative states of M. tuberculosis. All beta-lactam antibiotics, especially meropenem and imipenem, combined with clavulanate decreased viability of “persistent” M. tuberculosis. Meropenem and clavulanate in combination were equally effective against sensitive strains as XDR strains of M. tuberculosis in vitro.

This in vitro study provides promising data for the use of meropenem-clavulanate in the future treatment of M. tuberculosis, including MDR and XDR strains.

(Hugonnet JE et al. Science. 2009;223:1215-8)

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EIN: Better Testing for C. difficile

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The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of EIN, IDSA (EIN's sponsor), or the Centers for Disease Control and Prevention, which funds the EIN. The reader assumes all risks in using this information.

Some currently available tests for Clostridium difficile have relatively low sensitivity, and EIN members have been discussing how to get an accurate diagnosis quickly.

Some proposed protocols to repeat negative tests. But an EIN member from Georgia said, “Routine, repeat testing using the currently available EIA toxin A and/or B assays is likely not the best answer.” Repeating a negative test increases the likelihood of false positives. Waiting a few days between tests might improve their diagnostic power for patients who continue to have diarrhea. But, the member noted, “this defeats the purpose of earlier diagnosis and delays in treatment can spell disaster in some patients.”

The member added, “Accuracy in the diagnosis would likely improve if laboratories would routinely reject formed stool for testing and if testing was routinely ordered only for patients with three or more unformed stools in a 24 hour period.”

Another member from California recommended homogenizing stool samples. “Bacteria, and presumably toxins as well, are distributed irregularly throughout the fecal mass (although that is probably not so in the case of liquid stools)…We use a Waring blender inside an anaerobic chamber—not practical for a clinical lab, but maybe a Stomacher or simply mixing it up well by hand (with a stick or something, not the hand).”

“Why not use a two-step procedure?” another member suggested. “[Use] one of the immunoassay tests for C. difficile glutamate dehydrogenase antigen probes. They have a good negative predictive value and, if negative, one test is sufficient.”

In a separate thread, an EIN member asked if others had experience with the new PCR assays for Clostridium difficile infection.

One respondent noted that one commercially available PCR assay was more than 95 percent sensitive and specific compared to “gold-standard” toxigenic culture assay according to a poster presented at the Society for Healthcare Epidemiology of America’s annual meeting this March. The conventional ELISA assay for toxin A/B was only 50 percent sensitive in this manufacturer-sponsored study.

“Of 118 PCR-positive patients, 51 were identified only by PCR from their first study sample; only four of these had previously been diagnosed with C. difficile infection by ELISA,” the respondent said. “The increased cost of the assay must be weighed against the potential clinical benefit of rapidly and accurately diagnosing an additional 30 to 40 percent of patients with C. difficile infection.”

Another respondent from California added, “The speed (less than two hours) and sensitivity of the test are impressive, and would be helpful for initial diagnosis depending on index of suspicion. But it will also detect carriers. So the question may be whether it is too sensitive.” The respondent also noted that the PCR assay detects only toxin B genes and would miss rare but pathogenic toxin B-defective mutants, as well as non-toxigenic strains.

In a third thread on C. diff, an EIN member asked, “Is anyone familiar with a commercial lab that performs environmental C. diff cultures in a reliable and affordable manner?”

There were no responses to this question, highlighting the urgent need for more research regarding the role of the environment and testing for C. difficile.

E-mail the Emerging Infections Network.

The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public-health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) and supported by funding from the Centers for Disease Control and Prevention, EIN tracks emerging infectious diseases and keeps the public-health community up to date with issues that are currently affecting or may soon affect members’ clinical practices.The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. The EIN listserve allows members to discuss new disease trends and difficult cases. Click here for more information or to join EIN.

Drug Approvals, Recalls, Adverse Events Update

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IDSA offers two e-mail services to help members stay informed of updates from the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). Recent alerts have included:

IDSA members can sign up for these alerts online. (You must be logged in to have access to this link.)

In addition, FDA has launched a new hepatitis list serve. This new e-mail list will provide updates on safety and regulatory issues related to hepatitis B and C products. The e-mail list is intended to provide one source for FDA information on a variety of topics related to hepatitis B and C, including proposed regulatory guidances, opportunity to comment, and notices of upcoming public meetings. Sign up on FDA’s web page. (Please note that this page does not mention the hepatitis list serve. However, users receive notification that they have subscribed to the hepatitis list serve after they enter an e-mail address.)

Is Your Facility Experiencing Antibiotic Shortages?
Report these to FDA and IDSA.

Medical Societies Raise Concerns About Medicare Audit Program

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Medicare claims are getting extra scrutiny now that the Centers for Medicare and Medicaid Services (CMS) is rolling out the Recovery Audit Contractor program (RAC).

RAC is a congressionally mandated program to identify improper Medicare payments and fight fraud, waste, and abuse. However, physician groups think it has failed to achieve its goal of eradicating frequent billing mistakes.

Beginning in March, RAC auditors are being phased in across the country.

IDSA was one of more than 100 state and national medical societies that sent a letter this month to the Centers for Medicare and Medicaid Services (CMS) arguing that the Recovery Audit Contractors (RAC) program is not an appropriate vehicle for reducing billing mistakes and improving payment accuracy. 

In their letter, the medical societies say that evaluation and management (E&M) codes are not appropriate for the program because the various levels of E&M services pertain to wide variations in skill, effort, time, responsibility, and medical knowledge—so much so that knowledgeable individuals often reach different conclusions about the level of service justified by the documentation.

The medical societies are also concerned about allowing contractors to perform audits on consultations, given physicians’ confusion over Medicare’s current policies on split-shared billing, transfer of care, and documentation for consultations.

Moreover, the letter says, auditing E&M services threatens to overburden physicians at a time when many specialties are in increasingly short supply and impending baby boomer retirements will exacerbate existing shortages.

The medical societies believe that physician outreach and education would be a better way to reducing billing and coding errors.

Encouragingly, a CMS official said at the IDSA Clinical Affairs Meeting this March that E&M claims with a one-level coding difference would not be challenged—at least for the first year or two of the RAC program.

If you are audited unfavorably, you are encouraged to appeal. For contact information for appeals and more information about the program, go to

New HIV/TB Figures Call for Increased Funding, ID Center Says

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The Infectious Diseases Center for Global Health Policy and Advocacy responded to newly released figures on HIV-tuberculosis co-infection with a call to triple the U.S. contribution to the Global Fund to Fight HIV, Tuberculosis, and Malaria, and significantly increase domestic funding for TB control.

On World TB Day, March 24, The World Health Organization (WHO) released its latest estimate of HIV-TB coinfection indicating there were at least 1.37 million cases of HIV-TB co-infection worldwide in 2007—twice as many as WHO’s previous estimates.

In a press release, the Infectious Diseases Center for Global Health Policy and Advocacy noted that these figures come as the Global Fund faces a $5 billion shortfall and may be unable to fund anti-TB programs in nearly 60 countries. Global health advocates are concerned that the Obama administration will flatline vital HIV/AIDS and TB programs as the global recession deepens.

The Center held a teleconference with reporters, featuring Richard Chaisson, MD, director of the Johns Hopkins Center for Tuberculosis Research, and Carol Dukes Hamilton, MD, a professor of medicine at Duke University .

Dr. Hamilton noted that the Centers for Disease Control and Prevention’s budget for TB research has suffered in recent years, even as the global threat of TB grows. Dr. Chaisson talked about the need for new infection control measures and increased funding so that vital anti-TB programs, including those run by the Global Fund to Fight AIDS, TB and Malaria, can do a better job screening people with HIV for TB.

More on HIV/TB from the Center’s New Blog

Get the latest HIV/AIDS and TB news at, a new blog launched by the Infectious Diseases Center for Global Health Policy and Advocacy. We want this to be a resource for you to get up-to-date information on what’s happening in the field and what’s happening in Washington, DC.

We hope that you will visit this site and post your comments or questions. Please share the site with your public health students and colleagues. And send any story ideas you have to our resident blogger, Deirdre Shesgreen, at She is eager to get news from the front lines and hear about your work to combat global HIV/AIDS and TB.

IDSA Responds to Supermarketsí Free Antibiotics Promotions

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This winter, several national supermarket chains began offering free antibiotics with a prescription. In some cases, the promotions were linked to cold and influenza season, clearly encouraging inappropriate use. At a time when antibiotic resistance is on the rise, IDSA believes it is bad public health policy to be promoting the inappropriate use of antibiotics.

The Society issued a press release in January encouraging supermarkets to give away influenza vaccinations rather than antibiotics. IDSA and the Centers for Disease Control and Prevention (CDC) then wrote joint letters to the supermarkets encouraging them to partner with CDC’s “Get Smart: Know When Antibiotics Work” campaign to educate consumers about appropriate use, and issued a press release on the outreach.

Forum Makes the Case for Medicare Coverage of Home Infusion Therapy

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IDSA members participated in a Capitol Hill event to call attention to the need for Medicare to cover home infusion therapy.

The event, which included congressional office visits and a home infusion educational forum, was designed to educate legislators and their staff on the improved patient outcomes and satisfaction and lower costs that would result from Medicare coverage of infusion therapies in the home setting. Patients were on hand to talk about how the lack of Medicare coverage has negatively impacted them.

IDSA has endorsed the Medicare Home Infusion Therapy Coverage Act, which now has more than 50 House and Senate co-sponsors thanks in part to the efforts of IDSA members and local ID societies.

For more information, including how you can help support the bill, see  Please contact IDSA staff at if you would like to arrange a face-to-face meeting at your legislators' Capitol Hill or district offices.

Deadline Extended for Public Input on Lyme Disease Guidelines

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IDSA is extending the deadline for public comment on the Society’s 2006 practice guidelines on Lyme disease.

The guidelines recommend a single course of 10-28 days of antibiotics for most patients with Lyme disease, depending on the stage of their illness, with a second course of treatment occasionally being necessary. That recommendation has been criticized by advocates of long-term, intravenous antibiotic use.

Advocates of long-term therapy found an ally in the Connecticut Attorney General, who launched an antitrust investigation of IDSA that ended with no complaint being filed. IDSA is conducting the current review as part of the Society’s voluntary agreement with the attorney general, who questioned IDSA’s process but not its recommendations.

The Society convened a special panel to conduct a comprehensive review of the Lyme-related literature to determine whether the guidelines should be revised or updated. To ensure that all points of view are presented to and considered by the Review Panel, IDSA is soliciting comments from the public.

The deadline for submitting written comments has been extended to 5 p.m. Eastern time on April 24. Interested individuals and organizations may submit comments online. Comments should identify specific recommendations from the 2006 guidelines and evidence that either supports or refutes those recommendations.

An open public hearing, which had been planned for April 27, will be postponed to allow potential presenters more time to prepare and make travel arrangements. Individuals who wish to present at the hearing must submit their applications online by April 24.

“We are absolutely committed to hearing all points of view, so we pushed the dates back to give people more time,” said Carol J. Baker, MD, chair of the Review Panel.

The hearing will be broadcast live and will be archived for viewing on the IDSA website. Additional information, including how to apply to be a presenter, can be found at

For more information, contact

Welcome New IDSA Members!

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Akhtar, Kamran, MD
Calistru, Petre Iacob, MD, PhD
Fernandes, Prabhavathi, PhD
Oberhelman, Richard, MD
Rice, Charles, PhD
Rodriguez, Lourdes, MD


Casanova, Jean-Laurent, MD, PhD
Davenport, Stacey, MBA, PhD
Halsey, Jennifer, PharmD
Hopkins, Heidi, MD
McCarthy, Paul, MD
Mielle, Amaury, MD
Nagvekar, Vasant, MD
Ng, Wing Kee
Posluszny, Robert, BCh, MS, MSc
Samir-Moez, Hazem, MD
Seiter, Karen, MD
Soyemi, Kenneth, MD
Tamin, Kristen, RPh
Wahawisan, Joy, PharmD
Yongabi, Kenneth, MSc


Abuelo, Carolina, MD, DTM&H
Armstrong, Catharina, MD
Bark, Charles, MD
Barnabas, Ruanne, BCh, MB, PhD
Jinno, Sadao, MD
Mejia, Rojelio, MD
Murphy, Richard, MD
Muzaffer, Riffat, MD
Patel, Toral, MD
Patterson, Jennifer, DO
Ramsetty, Sabena, MD